Upper Extremity Musculoskeletal Exam Techniques: Evidence ...€¦ · 1 Upper Extremity...

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Upper Extremity Musculoskeletal Exam Techniques:

Evidence-Based Treatment of Common Upper-Extremity Injuries

Anthony Beutler, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated:

• Nitroglycerin patches for the treatment of lateral epidondylitis

Anthony Beutler, MD, FAAFPProfessor, Department of Family Medicine/Program Director, National Capital Consortium (NCC) Primary Care Sports Medicine Fellowship/Medical Director, Injury Prevention Research Laboratory, Uniformed Services University (USU) of the Health Sciences, Bethesda, Maryland

Dr. Beutler practices family medicine and comprehensive primary care sports medicine for the U.S. Air Force, caring for active-duty service members, retirees, and their families in the Washington, DC, area. He is an award-winning educator and teacher, and he and his team recently developed and implemented a new musculoskeletal curriculum for USU's medical school. The author of numerous articles and a textbook, Dr. Beutler has lectured throughout the world. One of his favorite activities is helping family physicians make their musculoskeletal practices more rewarding and profitable.

Learning Objectives1. Distinguish musculoskeletal conditions that result from

overuse/repetitive motion injuries in the upper extremities, with particular attention to those that occur in pediatric patients.

2. Assess an injured patient’s range of motion, stability, bone alignment, soft tissue swelling, palpable warmth or mass(es), pain or tenderness and crepitation in the upper extremities.

3. Identify red flags from the physical examination of upper extremity injuries that warrant referral to a sub-specialist (e.g. surgery, physical therapy) or for diagnostic imaging.

4. Apply evidence-based treatment strategies for patients with musculoskeletal injuries of the upper extremities.

Associated Sessions

• Upper & Lower Extremity Musculoskeletal Exam Techniques: PBL

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Audience Engagement SystemStep 1 Step 2 Step 3

Overview• Facts and Philosophy• 3 Common Conditions

– Victims and Culprits– Myths, Legends & Mystical Truths– Evidence-Based Treatment

• Coding Minute• Annoying Editorial Comments

Better Diagnose, Treat, and Code for Musculoskeletal Medicine

AES QuestionTell me about you...

Who are you?1. Family Medicine Resident

2. Family Medicine Staff or Family Med Trained

3. Peds

4. Other

AES Question –Have You Previously Attended an MSK

Session That I Have Taught?

1. Yes, at this AAFP conference

2. Yes, at a previous AAFP or other conference

3. No. And why is your nose so big?

AES QuestionHow Comfortable Are You Diagnosing &

Treating Common MSK Problems?

1. Not at all comfortable

2. Comfortable with the basics

3. Fairly comfortable with MSK

4. Confidently diagnose & treat MSK

Overview

• Facts and Philosophy• 3 Common Conditions



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Facts and Philosophy

Editorial CommentHow much Musculoskeletal Medicine (MSK) do

you See?

• 22-34% of outpt visits (civilian) for MSK complaints

• How much Musculoskeletal Medicine will you Know?

• MSK = 2% of Med School Curriculum (US & Canada)

Two Areas of Difficulty

• Proper History and Physical leading to correct Diagnosis

• Proven-Effective Treatments for the Correct Diagnosis




Case 1 –

Case 2 –

Case 3 –

• 44 yo male with R shoulder pain for 3 weeks

• No trauma, felt a little twinge after football game

• Pain runs from shoulder down to lateral arm

• Pain wakes him up at night, hurts with overhead activities

• Pain getting worse despite babying it for 3 weeks

3 Common Cases

Case #1

AES - What is Your Diagnosis?

A. Subacromial Shoulder PainB. Impingement SyndromeC. Rotator Cuff TendonitisD. Rotator Cuff TearE. AC Joint SprainF. Biceps Tendonitis

Rotator Cuff Syndrome

Differential Diagnosis

• Subacromial Pain

• Impingement Syndrome

• Degenerative Rotator Cuff Tear

• Rotator Cuff Tendonitis

• AC Joint

• Dislocation

• Frozen Shoulder


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Another Shoulder? Why Me??

Why we fear the Rotator Cuff….

“If you can’t do a GOOD

POORLY...”

“If you can’t do a GOOD shoulder exam, just learn

to enjoy doing it POORLY...”


Bony Anatomy

• 4 Daughters in a minivan…..

• History is KEY!


Non‐Shoulder Stuff Causing Shoulder Pain

Key History• Age (> 40)• No/Minimal/Repetitive

Trauma • Overhead Activities• ↓Activity, but ↑Pain• Night Pain• Radiates to Deltoid

Supporting Exam• + Hawkins or Neers• Painful Arc of Motion


How to Diagnose It

AC JointPain

Painful Arcof Impingement

No Pain

• Identifying The VICTIM– That’s easy

• Identifying The CULPRIT– Most common error:

Not Identifying/Treating the Culprit

Victims & Culprits

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Victims:– Rotator Cuff– Subacromial Bursa

Culprits:– Rotator cuff weakness– Subacromial spurs– Overuse– Scapula or core dysfunction

Treatments

NSAIDs

Iontophoresis / Ultrasound

Steroid Injection


Treating Victims and CulpritsVictims:

– Rotator Cuff– Subacromial Bursa

Culprits:

– Subacromial spurs– Overuse– Scapula or core dysfunction

Treatments

NSAIDs


Steroid Injection

RC strengthening Radiographs/MRI Correct training Find a good PT


Treating Victims and Culprits

• Glenohumeral Joint– Extreme mobility

– 30% humeral head in contact with glenoid

– Static and dynamic stabilizers


Shoulder & Golf

• Rotator Cuff– Smaller than more

superficial muscles– “Steering” mechanism

for humeral head– Depresses humeral

head into glenoid


Dynamic Stabilizers

What happens if my Stabilizers aren’t so Dynamic?


Culprits:– Rotator cuff weakness– Subacromial spurs– Overuse– Scapula or core dysfunction

Treatments

NSAIDs


Steroid Injection

RC strengthening Radiographs/MRI Correct training Usually high level athletes



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‐ Ekeberg, BMJ, Jan 2009‐ Holmgren, BMJ, Feb 2012

‐Litchfield, Clin J Sport Med, Jan 2013

Must Strengthen Rotator Cuff!!• Finding a good physical therapist

What about Pain Control?– NSAIDs vs Steroid Injection (anywhere?) – Hard to do good therapy and sleep while in pain– Rotator cuff rehab takes time, 6-24 weeks

If patient not improving, not responding…Find & Treat the Culprit

Rotator Cuff/Impingement Syndrome

Treating the Culprits AES Question

What is the “First Line, Must Do Treatment” for Rotator Cuff Syndrome?A. Strengthen rotator cuffB. Control inflammation with ice, NSAIDsC. Give a steroid injectionD. Rest for 3 weeks, then slowly return to

activity


Differential Diagnosis• Subacromial Pain

• Impingement Syndrome

• Degenerative Rotator Cuff Tear

• Rotator Cuff Tendonitis

• AC Joint

• Dislocation

• Frozen Shoulder


1st Line Treatment:

Rotator Cuff Strengthening

Welcome to the GRAMP-C’s

“Great Research; And Maybe Practice-Changing”

A Favorite Article on Subacromial Pain–“Subacromial corticosteroid injection or acupuncture with home exercises when treating patients with subacromial impingement in primary care--a

randomized clinical trial”

• Open label, multicenter randomized clinical trial• 117 patients visiting Swedish GP’s received:

– Steroid injection + Home PT– Acupuncture + Home PT

Findings:• At 3, 6, 9 months:

– 93% of patients improved• No difference between Acupuncture and Steroid Inj Groups

- Johansson K, FamPract. 2011 Aug;28(4):355-65

A Favorite Article on Subacromial Pain–“Subacromial corticosteroid injection or kinesiotape with home exercises when treating patients with subacromial impingement in primary care--a randomized

clinical trial”

• Open label, multicenter randomized clinical trial• 117 patients visiting Swedish GP’s received:

– Steroid injection + Home PT– Kinesiotaping + Home PT

Findings:• At 3, 6, 9 months:

– 93% of patients improved• No difference between Kinesiotaping and Steroid Inj Groups

- Subasi V, Clin Rheum. 2014

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Piling On Award – Exercises Work!Effect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Pain: A

Randomized Controlled Study

Progressive Strengthening Exercises for Subacromial Impingement Syndrome

• Randomized trials of Specific Rotator Cuff Exercises versus General Shoulder Stretches

• 200+ patients, all on waiting list for surgeryFindings:• Exercises take time (12+ weeks of exercise therapy)• Exercises:

– Reduced Pain– Improved Function– Decreased Subsequent Surgery

• Specific Rotator Cuff MUCH BETTER than General Shoulder Stretches- Litchfield R, Clin J Sport Med, 2013; Holmgren T, BJSM, 2014

“Great Research;

And…”

GRAMP-C’s

“Maybe Practice‐

Changing”

1st Line: Rotator Cuff Strengthening2nd Line: Supervised Rot Cuff StrengtheningNext Step: ?

Treatment of Rotator Cuff Syndrome with Steroid Injection

‐ Ekeberg OM et al. BMJ 2009

• Randomized Controlled Clinical Trial• Double‐blind and Placebo‐controlled• Steroid vs Saline Injection

Results: Steroid better than Saline, butt…


Culprits:

– Subacromial spurs– Overuse– Scapula or core dysfunction

Treatments

NSAIDs


Steroid Injection

RC strengthening Radiographs/MRI Correct training Usually high level athletes



#1 Rot Cuff Strength, #2 Mo’ RTC Strength, #3 +/‐Steroid




Case 1 – Rotator Cuff Syndrome

Case 2 –

Case 3 –

• Just over 40 yo female with L elbow pain for 6 weeks

• Felt a little twinge after tennis 6 weeks ago

• Pain gradually progressed, stopped playing tennis 2 wks ago

• Aches at night, hurts with any wrist/elbow activities

• Pain getting worse despite babying it for 2 weeks

3 Common Cases

Case #2

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AES Question

What is Your Diagnosis?

A. Elbow Osteoarthritis

B. Lateral Epicondylitis (Tennis Elbow)

C. Medial Epicondylitis

D. Olecranon Bursitis

• NOT an inflammatory condition (not an “–itis”)

• Microtears of the wrist extensor tendons

• Subsequent collagen degeneration XLateral Epicondylitis

Pathoanatomy

Clues to Diagnosis

• No numbness/tingling

• Lateral elbow

• Tennis

• Age

Lateral Epicondylitis

DiagnosisLateral Epicondylitis

Differential Diagnosis

Victims:– Wrist Extensor Tendons (ECRB)

Culprits:– Overuse– Eccentric Contraction– Tennis Racquet– Scapula or core dysfunction (weakness)

Treatments

NSAIDs

Steroid Injection

Physical Therapy

Bracing

Novel Injections

Surgery


Treating Victims and Culprits Myths, Legends &Magical TruthsAbout Treatment

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AES QuestionClassical Teaching For Lateral Epicondylitis:

_______ provides best pain relief for initial 6 weeks;___________ is best beyond 6 weeks.

1. NSAIDs; Counterforce Brace

2. Steroid Injection; Physical Therapy

3. Counterforce Brace; Steroid Injection

4. NSAIDs; Steroid Injection

AES Question:What therapy has been shown to improve LatEpicondylitis outcomes in patients already doing PT?

1. Topical Nitroglycerin Patch

2. Steroid Injection

3. NSAIDs

4. Friction Massage

5. Yoga

NSAIDSRemember that lateral epicondylitis pain is non-inflammatory!

• “Very limited evidence to recommend the use of NSAIDs…”

• Topical NSAIDs possibly more effective than oral• “Injection may be more effective than oral

NSAID in the short term.”– Pattanittum, Cochrane Database 2013 May

“To Brace or Not to Brace…”Brace vs Physical Therapy:

• Brace might decrease symptoms for first 6 wks

• PT better throughout study• Combination therapy?• No studies suggest harm

Struijs, Am J Sports Med. 2004

Injection vs Physical TherapySteroid vs Physical Therapy:

• Steroid: best short-term pain relief (< 6wks)

• PT: best results > 6wks– Stretching– Eccentric Strengthening

• Combination Therapy?Tonks, IntJ ClinPract. 2007 FebBisset, BMJ, 2006Smidt, Lancet. 2002

Lateral Epicondylitis:Novel Treatment Studies

• Topical Nitric Oxide Application at the ElbowA Randomized, Double-Blinded, Placebo-Controlled Clinical Trial

– Paolini JA, Appleyard RC, Nelson J, Murrell GA: The American Journal of Sports Medicine 2006; 31(6): 915-920.

• All patients got Physical Therapy

• 81% cure with nitro at 6 months– ¼ of a 0.1mg or 0.2mg ntg patch daily

• 60% of the placebo group. P=.005

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Not Worth the Electrons, Let Alone the Paper –2012

“Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis: A Randomized Controlled Clinical

Trial”

• 28 patients with new Lateral Epicondylitis– Group 1 – Autologous Blood Injection & Rehab

– Group 2 – Platelet Rich Plasma (PRP) Injection & Rehab

• ~ 50% of patients got better

• No real differences between groups- Rompe JD, J Bone Joint Surg Am. 2010 Nov 3;92(15):2514-22

Game Changer Study“Steroid injection, physiotherapy, or both for lateral epicondylagia”

• 165 patients with new Lateral Epicondylitis• 1 Year Follow-up

– Group 1: Steroid Injection Group 3: Steroid + Rehab

– Group 2: Placebo Injection Group 4: Placebo + Rehab

• Lower recovery and higher relapse rate in steroid group than placebo group at 6 & 12 months

• Both placebo groups did equally well at all times• Only caveat: Rehab program really NOT very good

• Coombes BK, JAMA, 2013 Feb

2nd Game ChangerSystematic Review of Exercise Therapy for Lateral Epicondylitis

• 12 RCTs and 1 Review of Exercise Therapy for LE

• “Good evidence for efficacy of stretching plus strengthening exercise”

• “Good evidence for eccentric strengthening”

• Stretching plus strengthening outperformed all other modalities (friction massage, ultrasound, etc.)

• Hoogvliet P, Br J Sports Med, 2013 May

Wow! You Really Got That Thru an IRB?

“Effectiveness of Leech Therapy in Chronic Lateral Epicondylitis”

• Randomized Controlled Trial (Imagine the suspense….)• 2-4 Leeches applied daily• Versus diclofenac topical cream

Findings:• Leeches less pain, maybe less disability

Backer M,Clin J Pain. 2011 Jun;27(5):442-7

Victims:– Wrist Extensor Tendons (ECRB)

Culprits:– Overuse– Eccentric Contraction– Tennis Racquet– Scapula or core dysfunction (weakness)

Treatments



#1– PT (+eccentric), #2– PT+NTG patch , #3– Leeches or Novel Inject

Childress MA, Am FamPhysician, 2013 Apr

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Case 2 – Lateral Epicondylitis

Case 3 –

• 25 yo G1P1, four weeks post-partum

• Right wrist painful for 8 days, no trauma

• Hurts with any thumb movement

• Can’t change diapers, can’t pick up baby, can’t breastfeed, can’t sleep

• (Here she collapses into sobs) “I’m just a bad mom!”

4 Common Cases

Case #3

AES QuestionWhat is your diagnosis?

A. Trigger finger

B. Carpal tunnel

C. de Quervain’s tenosynovitis

D. Post-partum depression

Clues to Diagnosis

• Sharp radial wrist pain

• Atraumatic

• Thumb movement

• Classic patient: new breastfeeding mom

– Why??

de Quervain’s Tenosynovitis

Diagnosis

Can Men Get de Quervain’s?

• FINALLY, an “–itis” that IS inflammatory!!!

• Tendon sheaths and Brake Cables

• Inflammation between sheath and tendon causes


Pathoanatomy

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Victims:– Abductor/Extensor Pollicis Tendons

Culprits:– Overuse– Hormones– Baby

Treatments

NSAIDs

Steroid Injection

Bracing

Surgery


Treating Victims and Culprits Myths, Legends &Magical TruthsAbout Treatment

NSAIDs

• Inflammation present pathologically

Bracing

• Insufficient as a solo therapy

• Is it a helpful adjunct?

Steroid Injection

• Is this a good idea?

• What are the risks?

AES QuestionWhat is the best first-line treatment for de Quervain’s?A. NSAIDs and RestB. Brace and RestC. Steroid InjectionD. Steroid Injection, Brace and Rest

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Treatment StudiesRest vs NSAIDs vs Brace vs Steroid

• Pooled analysis of 7 studies

• Cure rates:– Rest – 0%

– NSAIDs – 0%

– Bracing alone – 17%

– Steroid injection (X1) – 83%

– Injection + brace – 65%

Ritchie, J Am Board FamPract. 2004



Treatments

NSAIDs

Steroid Injection

Bracing

Surgery



Injection Safe in Pregnancy & Breastfeeding!

‐‐ Acici, J Hand Surg, 2002



“Great Research;

And…”

GRAMP-C’s

“Maybe Practice‐

Changing”

1st Line: Steroid Injection2nd Line: Mo’ Steroid InjectionNext Step:

1-Point versus 2-Point Injections For de Quervain’s

• 10mg triamcinolone + 1cc lidocaine

• 40 pts (43 hands)

• 36 month f/u

• Results:

• 1-pt injection:

– 89% “good” efficacy

• 2-pt injection

– 100% “good” efficacy Sawaizumi T, Int Orthop. 2007 April; 31(2): 265–268

2-Point versus 4-Point Injections For de Quervain’s

• 6mg Celestone + 1cc lidocaine

• 48 pts (all male??)• 2, 4, 8, & 52 wk f/u• Results:

4-point injection had:– Better sx scores– Less surgeries– Fewer relapsesAt all f/u time points Pagonis T, Am J Sports Med. 2011 Feb;39(2):398‐403

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What’s Going On?• Real effect?

• Needle phobia

• Tenotomy?

• Effects likely due to variations in anatomy/multiple sheaths



Treatments

NSAIDs

Steroid Injection

Bracing

Surgery



Injection Safe in Pregnancy & Breastfeeding!

‐‐ Acici, J Hand Surg, 2002#1‐ Steroid Injection, #2 – Mo’ Steroid Injection, #3 – U/S Inj



• Coding Minute



Case 3 – de Quervain’s Tenosynovitis

Coding MinuteTake Credit For What You Do

• Military Disclaimer

Coding MinuteTaking Credit For What You Do

5 Do’s and Don’ts of Coding

1. Do capture time required for:– Exercise Teaching (E&M or CPT 97110)

– Crutch Training (E&M or CPT 97116)

– Brace Fitting and Care Coordination (E&M)



1. Do capture time required

2. Don’t forget to code injections– Most injections - CPT 20610

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1. Do capture time required

2. Don’t forget to code injections

3. Do use a 25 or 29 modifier– Diagnosis and treatment in same visit requires

the modifier in many states


5 Do’s and Don’ts of Coding1. Do capture time required2. Don’t forget to code injections3. Do use a 29 modifier4. Don’t forget to bill Durable Medical

Equipment– Ankle braces, crutches, etc…


5 Do’s and Don’ts of Coding1. Do capture time required2. Don’t forget to code injections3. Do use a 29 modifier4. Don’t forget to bill DME5. Do phone a friend

– Orthopedic coder– Ortho P.A.– Ortho R.N.


– Victims and Culprits– Evidence-Based Treatment

• Coding Minute



Case 3 – de Quervain’s Tenosynovitis

Practice Recommendations• Rotator Cuff Syndrome

1st Line: Rotator Cuff Strengthening

2nd Line: Supervised Rotator Cuff Strengthening

3rd Line: Steroid Injection (anywhere!) and Mo’ Rotator Cuff Strengthening

• Lateral Epicondylitis1st Line: Stretching and Strengthening Exercises

2nd Line: Nitro Patch + Stretching and Strengthening Exercise

3rd Line: Novel Injections + Eccentric Exercise

• de Quervain’s Tenosynovitis1st Line: Steroid Injection

2nd Line: Mo’ Steroid Injection

3rd Line: Ultrasound guided exam and injection

Questions

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Think I’ve Stretched the Truth?

Anthony Beutler, MDCol, USAF, MC

Professor, Dept Family Medicine

Uniformed Services University

[email protected]

Washington D.C. Stretch Limo Preston Idaho Stretch Limo

Evidence‐Based Treatments for Upper Extremity Injuries

Very Special Thanks to our models: Kathy Fields, Melanie McGrath, Quinton Sawyer, and Michelle Boling

• 42 yo postal worker• Right hand/fingers go numb at

night, shakes them out• Pain and tingling starting at

work when sorting mail• Dr. Google: carpal tunnel?• Wearing brace, but not helping• “Don’t want to be a workman’s

comp guy…”

4 Common Cases

Case #4

Clues to Diagnosis

• Nighttime numbness and pain

• Vocation

• Shaking it out

• How do you know it’s carpal tunnel?

Carpal Tunnel Syndrome

Diagnosis

Clinical “Syndrome” = Clinical Diagnosis

Clinical Findings

• Typical “Median” Distribution– ~93%


Clinical Findings• “Median” distro 93%

• Phalens versus Tinnels– P – 68%, 73%

– T – 50%, 77%

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• Pha/Tin 60%, 70%

• Hand Symptom Diagram – 64% sensitive

– 73% specific



• Pha/Tin 60%, 70%

• Hand Symptom Diagram 64%, 73%

EMG Findings

• Nerve Conduction Tests– 70% Specific

– 78% Sensitive

Myths, Legends &Magical TruthsAbout Treatment

NSAIDs• 2003 Systematic Review

– 1 RCT on NSAIDs – Trial showed NO EFFICACY of NSAIDs

- O’Connor, Cochrane Rev, 2003

• Conclusions:– Limited evidence suggests NSAIDs not effective

• Why?

Bracing/Splinting

• Effective for mild or moderate symptoms

– Duration of symptoms

– Night-time vs 24 hr?

– Neutral vs Cock-up

SteroidsInjections:• Modestly effective for

mild – mod symptoms• Lasts 4-6 weeks

Oral Steroids• Less effective than

steroid injection• Benefit lasts 6-8 wks

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Combination Therapy

• Symptoms < 3 months

• Normal sensory exam at presentation

• Bracing

• Steroid Injection Predicts good response to conservative treatment

Graham, Plast Reconstruct Surg, 2004; O’Connor, Coch Rev, 2003

Surgery• Very Successful

– 75% overall “success”

• Minimal Risk/Invasive

• Absolute Indications– Muscle weakness– Thenar atrophy– Baseline sensory abnl– Severe pain/symptoms– Severe EMG findings

• Relative Indications– >6 months of symptoms– No response to adeq.

conservative treatment– Recurrent symptoms



Carpal Tunnel Synthesis 2013

• Gabapentin (still) Not Effective- Hui AC, Eur J Neurol. 2011 May;18(5):726-30

• Acupuncture Systematic Review = Not Likely Effective-Sim H, J Pain. 2011 Mar;12(3):307-14

• Astaxanthin (beta-carotinoid) Not Effective - Macdermid JC, Hand, 2012 Mar

Carpal Tunnel Synthesis 2013 (Continued)What is Effective?

• Surgery still works VERY well (Shi Q, J Orthop Surg Res 2011)– So should we just skip everything else and operate on all?

• Steroid injection may work better than we thought....– 824 carpal tunnel patients over 6 years– Each received steroid injection– Followed for 5 years

• Rate of carpal tunnel surgery at 1 year: 15%• Rate of carpal tunnel surgery at 5 years: 33%

- Jenkins PJ, Hand, 2012 Jun

Victims:– Median Nerve

Culprits:– Overuse

– Hormones

– Unneighborly flexor tendons

– Bad karma

Treatments

NSAIDs

Steroid Injection

Bracing

Yoga

Mobilization

Nerve Gliding

Surgery

Carpal Tunnel Syndrome


B

B+B++

BB ‐

B ‐

A

If Short Duration, Mild Sx: Bracing and Injection. Otherwise: Surgery

Upper Extremity Musculoskeletal Exam Techniques: Evidence ...€¦ · 1 Upper Extremity...

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Transcript of Upper Extremity Musculoskeletal Exam Techniques: Evidence ...€¦ · 1 Upper Extremity...